- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.47 / $835.47 / $835.47
| Facility | | $835.47 | $835.47 | $835.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.80 / $1,411.94 / $2,213.31
| Facility | | $1,028.80 | $1,411.94 | $2,213.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.00 / $1,944.84 / $2,550.77
| Facility | | $1,554.00 | $1,944.84 | $2,550.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.41 / $1,383.89 / $1,577.79
| Professional | | $1,044.41 | $1,383.89 | $1,577.79 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $310.77 / $310.77 / $310.77
| Professional | 80 | $310.77 | $310.77 | $310.77 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $310.77 / $310.77 / $310.77
| Professional | AS | $310.77 | $310.77 | $310.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,643.00 / $1,643.00 / $1,643.00
| Facility | | $1,643.00 | $1,643.00 | $1,643.00 |